Introduction

The previous chapter discussed assessment, diagnosis, and formulation. To reiterate here, assessment and intervention go hand in hand. While that may appear obvious, the reality is that in community settings, treatment options may not be appropriately matched for reasons such as clinician training and competence, availability of a broad range of evidence-based practices (EBPs) at a clinic, or even limitations of insurance authorization (e.g., attempting to deliver cognitive-behavioral therapy (CBT) in an ecosystemic structural family therapy program). This chapter aims to equip clinicians with a baseline understanding of psychosocial intervention. The chapter will be broken down into sections about treatment modalities, theoretical approaches, and responsive treatment.

A Cursory Note About Evidence

Evidence-based practices (EBP) are interventions supported by evidence consistently demonstrating that the intervention is effective in improving client outcomes (Drake et al., 2001). The term evidence-based practice was articulated in Sackett’s (1997) definition of evidence-based medicine as the conscientious, explicit, and judicious use of evidence in care decisions for patients. This definition includes three core components for decision-making: 1) the best external evidence, 2) the individual practitioner’s expertise or competence with the intervention, and 3) the patient’s preference regarding their care (Sackett, 1997).

There are varying levels of external evidence based upon strength. The original tiers of evidence strength from Sackett (1986) comprise the following: Level 1 includes large, randomized control trials (RCTs) with clear cut results; Level 2 includes small RCTs with unclear results; Level 3 includes cohort and case-control studies; Level 4 includes historical cohort or case-control studies; and Level 5 includes case series and studies with no controls. Different professional bodies and journals have adapted these levels (Burns et al., 2011), but RCT studies are consistently considered the gold-standard for evidence. Southam-Gerow et al. (2014) present another way to view levels of evidence across the following tiers: Level One: Works Well, Well-established Treatments; Level Two: Works, Probably Efficacious Therapies; Level Three: Might Work, Possibly Efficacious Therapies (i.e., “promising therapies,”); Level Four: Unknown/Untested, Experimental Therapies; and Level Five: Does Not Work/Tested But Did Not Work. As you read through the chapter, keep in mind the three tenets of EBP, and hopefully this baseline understanding will allow you to be more confident in matching client need with available interventions rooted in the scientific literature.

Intervention and Treatment Modalities

When working with a child or adolescent, be mindful of who you are treating, where you are treating them, and in what capacity you are intervening. The following section covers individual versus family approaches, considerations of setting (particularly the school setting), and the scope of how to intervene with a youth.

Who’s Involved: Individual Treatment

Individual treatments focus on the youth themselves. The developmental systems approach should still be present here; even if treating individually, the youth is situated in a particular setting and among a constellation of other ecological and developmental factors. Individual treatments discussed in this chapter fall under three categories: behavioral, cognitive-behavioral, and psychodynamic, and these categories do not represent individual intervention in its entirety.

We discuss theoretical approaches in more detail later, but here is a brief summary of the major types of therapies. Behavior therapy involves techniques or protocols that have some elements of classical conditioning or operant conditioning (Donnelly, 2015). These models are based on stimulus-response pairings, intended to increase or decrease behaviors (Donnelly, 2015). Techniques under this umbrella of therapy include behavior modification, behavioral activation, exposure, desensitization, and parent-training. (Donnelly, 2015) Cognitive-behavioral therapy (CBT) builds upon behavioral therapies and emphasizes the cognitive mediation that occurs between a stimulus and response (Rice, 2015; Sperry, 2015). CBT has been widely researched and is known to be effective for various conditions such as anxiety and depressive disorders, substance use disorders, attention-deficit/hyperactivity disorder, externalizing disorders, and psychosis (Rice, 2015; Sperry, 2015). Psychoanalytic or psychodynamic therapies tend to focus on insight building, with the assumption that increasing insight and awareness about patterns of behavior can lead to changes in those patterns (Bishop, 2015). Transdiagnostic approaches synthesize different theories and protocols to broaden the coverage of treatment (Barlow et al., 2004; Ehrenreich et al., 2009) Again, these approaches will be detailed later in the chapter. It should be noted that a review of all modalities is beyond the scope of this chapter.

Who’s Involved: Family Involvement and Family Therapy in Treatment

Family involvement is a general clinical rule for working with children and adolescents. Family work will vary by the developmental age of the child or youth and the extent to which engagement with the child/youth and involvement of the family is possible. As children get older, especially after age 13 or 14, respecting the youth’s wishes is usually the most important consideration for how much to encourage family involvement. We should be able to build and maintain our relationship with the family and youth if we understand some of the family dynamics. Assessment of family functioning is always helpful, even if you choose to work individually with a child. Every family is unique with its own blend of strengths and competing demands, and it takes some effort, engagement, and partnership to make things work. The definition of family may vary, too, so be mindful of how families organize themselves. Family-based therapies operate through engagement of the family systems and viewing child behavior as the process of interactions between family members (Tabbi, 2015).

There are different approaches to family-based therapy. Focusing on parenting alone has shown great impact, with studies evidencing that parent involvement in therapy is a moderator for child conditions in general (Hoagwood et al., 2010), and specifically for concerns such as trauma (Gutermann et al., 2016), child internalizing disorders (Diamond et al., 2016) and child externalizing disorders (Ward et al., 2016; Baldwin et al., 2012; Woolfenden et al., 2002). Involvement can include direct parent-management training such as Parent Child Interaction Therapy (PCIT; Ward et al., 2016), incorporation of parents into individual treatment protocols (Gutermann et al., 2016; Epstein et al., 2017; Cohen et al., 2010), or work with child-parent dyads (Diamond et al., 2016). Social-ecological models of family therapy, such as Multisystemic Therapy, have demonstrated favorable results for families with children at risk for out-of-home placement (Henggeler & Schaeffer, 2016), and Functional Family Therapy has consistently demonstrated effectiveness for children with conduct problems (Hartnett et al., 2016). These family interventions are delivered with the family unit and usually conducted in the home. Thus, whether there is a focus on the parent or on the unit as a whole, families are the context for youth treatment in family therapies.

Where’s It Happening: Settings and Contexts

Youth often spend a majority of their day at school, so it is important to understand how to harness the natural setting of the school as a place for mental health promotion. Meta-analyses indicate that when compared to community-based services, school-based services are more accessible, decrease disparities in service use, and keep youth in treatment longer (Sanchez et al., 2018; Barnes et al., 2014). The treatment gap especially affects racial and ethnic minorities who tend to receive less treatment and less effective treatment compared to their non-Latinx White peers (Barnes et al., 2014). Intervention in schools spans treatments such as Cognitive Behavioral Intervention for Trauma in Schools (Stein et al., 2003), social skills interventions, behavior therapies, brief counseling, or intervening in a way to support the child as a whole through functional interventions. Functional interventions are those that focus on the relationship between the youth and the environment, oftentimes the school environment (O’Neill et al., 2017). Considering our developmental systems focus, our direct practice occurs in the context of the various systems in a youth’s life, so functional intervention is essential. These types of interventions can arise through formal plans like Individualized Education Programs (IEPs), Section 504 Plans (which incorporate changes from the Americans with Disabilities Act (ADA) Amendments Act of 2008), or other school accommodations.

Functional work directs us to take a step back to look at the overall context of a child’s life. There are many other domains to consider when delivering interventions that broadly impact functioning. As a clinician, you may be the one to initiate discussions about attending to physical health (e.g., ensure connection to pediatricians, dentists); sexual health (e.g., direct psychoeducation or connection to healthcare agencies with the collaboration of the parent); prosocial and community engagement opportunities, (e.g., linkage to school programming, mentoring, opportunities for employment, volunteering, civic engagement), and accessibility across these domains (e.g. considering disability supports).

Teletherapy Considerations. The onset of the COVID-19 pandemic has led to the rapid global adoption of telehealth and teletherapy practices (Moreno et al., 2020). Overnight, community mental health providers have been compelled to turn to video or audio-conferencing platforms as their primary and, in many cases, only method of delivering therapeutic services to their clients. While teletherapy has long been supported as an effective method of delivering EBPs for various mental health disorders, including depression, post-traumatic stress disorder, and serious mental illness (Backhaus et al., 2012; Miu et al., 2020), it was not widely implemented prior to the pandemic due to provider concerns about client safety and privacy, negative perceptions of its feasibility and acceptability, and lack of financial and reimbursement incentives (Cowan et al., 2019). While the shift to telehealth was unprecedented and sudden, maintaining teletherapy as a part of routine care beyond the crisis may lead to long-term advances in children’s mental health service delivery and reductions in mental health care disparities. Teletherapy has the potential to increase access to evidence-based mental health care for marginalized communities, especially for socioeconomically marginalized, disabled, or rural populations with barriers to transportation or low proximity to quality mental health providers (Kataoka et al., 2002; Wright et al., 2017). Recent literature has identified several vital recommendations to support the continued use of telehealth services, such as reimbursement through permanent policy changes, training of mental health professionals in telehealth topics (e.g., technology, administrative aspects, clinical engagement), and technical and other support provision to clients using telehealth services (Lombardi et al., 2021).

Additional research is needed to understand who should implement these supports and at what level, as well as how these supports might address barriers to teletherapy. Furthermore, certain therapeutic strategies may need to be adapted or supported by additional telehealth resources (e.g., visuals such as PowerPoints or videos, interactive functions like Zoom whiteboards and screensharing, and use of chat functions) to increase therapeutic engagement, clarity, and efficacy in teletherapy settings (Craig, Iacono, Pascoe, & Austin, 2021). Lastly, it should be noted that teletherapy may not be an effective method of delivering EBPs for certain populations who have difficulty using or engaging in telehealth services, such as older clients with low technological literacy, clients with hearing loss, and young children.

Theoretical Approaches to Intervention and Treatment

The developmental systems lens considers ecological and developmental aspects of caring for youth. Within this, a clinician may have a particular or eclectic theoretical orientation regarding theories of change.

Psychodynamic

The psychodynamic approach has roots in the theory developed by Sigmund Freud. The core aspects of this theory are that human behavior and functioning can be explained by dynamic drives of a human being towards pleasure, aggression when well-being is threatened, mastery to influence the environment, and competence (Bishop, 2015; Walsh, 2014). In psychodynamic theory, these drives are understood through the functions of three structures of our psyche, which Freud labeled as the id, ego, and superego. The id contains drives whereas the superego functions as the moral compass and ethical center of the psyche. The ego is the glue that holds these structures all together, and it attempts to bring balance to the psyche through defenses that can help facilitate the activities of our psyche. These defenses include (1) awareness of external environment, or the actual perception of world; (2) judgment, or the capacity to choose behaviors likely to promote our movement towards goals; (3) sense of identity, or the coherent physical/psychological sense of self; (4) impulse control, or the ability to distinguish between primary (drives) and secondary (planned) mental processes; and (5) thought process regulation, or the ability to remember, concentrate, and assess situations to initiate appropriate action (Bishop, 2015; Walsh, 2014). For more on Freud and his influence on psychology, consult the open access materials of Psychology, 2nd edition.

Direct Applications. In working with children and adolescents, psychodynamic approaches focus on insight building and on the emotional life of the child. Play therapy is suggested to be heavily influenced by psychodynamic theory through its use of projective techniques (Kool & Lawver, 2010). Another treatment concept influenced by psychodynamic theory is understanding a child’s attachment style in early relationships, which can dictate how a child attempts to get their needs met from their caregiver. A child’s early attachment relationships can have influences on the quality of that child’s later relationships in adulthood.

Behavioral

Behavior theory focuses on increasing or decreasing behaviors based on stimulus-response pairings (Donnelly, 2015). A behavior therapist helps the client learn a new response to a stimulus with a previously undesired behavior response. One example is exposure therapy for a phobia or trauma. It is common for a client to engage in an automatic avoidance response of the feared stimulus, and the momentary relief reinforces the behavior of avoidance. The problem with this cycle is that the client will continue to avoid the feared object, which can in turn lead to functional impairments. Exposure therapy attempts to break the avoidance cycle so the client can learn that anxiety is not dangerous and that the feared object is not inherently dangerous.

Direct Applications. Exposure is one type of behavioral approach to therapy, and other common approaches include use of a token economy (Donnelly, 2015) that resembles a points or rewards system for engaging in desired behaviors. This is used frequently in parent training-based therapies, an approach focused on using behavioral learning principles to modify undesirable behavior (Baer et al., 1968). Behavior activation is a technique commonly used with clients with depressive symptoms; for instance, exercise or socialization can be a way to break a cycle of inactivity or anhedonia.

Cognitive and Cognitive-Behavioral

Cognitive theory has many influences: pragmatism where challenges are naturally met with inquiry or problem solving; logical positivism which focuses on verifiable information, analysis and clarification of language; information processing theory which centers on processing information and on correcting cognitive “errors” (Rice, 2015; Sperry, 2015, Walsh, 2015). Cognitive Theory was developed by psychiatrist Aaron Beck in the 1960s (Beck et al., 1979), and his legacy lives on through the Beck Institute.

Core components of cognitive theory include a focus on cognitions, which span our beliefs, assumptions, expectations, and ideas about the causes of events, attitudes, and perceptions in our lives. It also includes emotions that are physiological responses that follow cognitive evaluation of input, as well as activating events that produce a belief or thought that in turn produces an emotion reaction or action (Rice, 2015; Sperry, 2015, Walsh, 2015). In other words, this model indicates a linear process wherein an activating event (or stimulus) is filtered through a belief about the event, and results in a consequence by way of an individual’s emotional reaction or action based on their belief (Rice, 2015; Sperry, 2015, Walsh, 2015). This model extends beyond behaviorism, where there is only a stimulus and a response. In this model, cognitions mediate the relationship between the stimulus and a person’s response. Furthermore, in cognitive theory, a person develops core beliefs about themselves, others, or the world as a result of their life experiences, which can become the lens through which they view the world (Walsh, 2015).This potentially gives rise to frequent unhelpful or negative interpretations of events.

As mentioned previously, cognitive-behavioral therapy (CBT) builds upon behavioral and cognitive theories (Rice, 2015; Sperry, 2015). This theory considers a bidirectional relationship between thoughts, feelings, and behaviors (Walsh, 2015). If one can reframe or balance unhelpful or maladaptive thoughts, then there can be a resultant impact on feelings and behaviors; conversely, a behavior change can exert influence on thoughts and feelings.

Direct Applications. When working with thoughts, some basic approaches involve psychoeducation about the cognitive model and the cognitive triangle. The cognitive triangle demonstrates the bi-directional influence of thoughts, feelings/emotions, and behaviors. Cognitive coping strategies center on understanding and identifying automatic thoughts, particularly automatic negative thoughts. These thought types include cognitive distortions or “thinking traps,” such as overgeneralization, all or nothing thinking, shoulds/oughts, or filtering. For more about these types of thoughts and explaining them to children, consult Trails to Wellness. Understanding someone’s thoughts can help to understand the notion of managing positive or negative self-talk. Thought records can be helpful tools for clients to develop awareness of and insight into their own thoughts, feelings, and actions, as well as any patterns that emerge. Behavioral approaches have been described above, so consider now, what are the effects of behavior changes on someone’s thoughts?

Solution-Focused

Solution-focused therapy is considered a postmodern theoretical approach that borrows from other theories, with the overarching goal to develop solutions, discover exceptions to problems, enhance awareness of strengths, and learn to act and behave differently (Walsh, 2014). It is a brief treatment model that focuses on changing, not curing, the most pressing (not all) concerns of the individual, where problem origins are not essential for intervention. This approach theorizes that people have learned behaviors from their family of origin and develop a limited range of response patterns in relation to life problems; further, it theorizes that language shapes reality (Walsh, 2014).

Direct Applications. Assessment and intervention can occur simultaneously. Techniques used within the solutions-focused approach include (1) employing a scaling exercise to gauge client willingness to invest effort into problem resolution; (2) refraining or ignoring limitations and negative attributes; (3) asking strengths-reinforcing coping questions such as “How have you been able to manage so far? How has this not gotten worse?”; (4) using exception questions such as “What was different in the past when the problem wasn’t a problem?” or “What are you doing when the symptom isn’t happening?”; and (5) guiding the client to imagine a life where the problem is no longer there and work towards steps to actualize that imagined life. For more on different approaches, consult the work of the Institute for Solution-Focused Therapy.

Narrative

Narrative therapy is another post-modern approach that borrows from various theories and philosophies such as existentialism, symbolic interactionism, multiculturalism, and postmodernism. It focuses on the subjectivity of the individual, the possibility of choice and freedom, and the understanding of knowledge and power dynamics that contribute to grand narratives that are rooted in social context (Walsh, 2014). The overall approach of narrative therapy is to help the client recognize that they are already engaged in an ongoing process of constructing a life story, and therapy becomes the opportunity to reauthor a story that uncovers cultural influences, unique outcomes, and “sparkling moments” of the person’s life.

Direct Applications. Narrative therapy theory suggests that the problem is the problem. Techniques include externalizing the problem from the person and focusing more on insight rather than on problem solving, as well as mapping the effects of the problem on the person (and vice versa), considering the person’s strengths, expectations, and competence. Narrative therapy is used in other therapies such as narrative processing within trauma-focused cognitive behavioral therapy (i.e., trauma narrative). In the context of racial socialization and racial identity development, narrative approaches can help to build the individual’s story against the backdrop of their collective narrative.

Family Systems

Family systems approaches originates from the Bowen family systems theory, which uses systems thinking to understand the interactions of the family as an emotional unit (Bowen Center for the Study of the Family [BCSF], 2021). It assumes that family members are interconnected and reactive to each other’s thoughts, feelings, and actions (BCSF, 2021). The eight core concepts identified within Bowen Family Systems therapy consist of: triangles, differentiation of self, nuclear family emotional process, family projection process, multigenerational transmission process, emotional cutoff, sibling position, and societal emotional process (BCSF, 2021).

Direct Applications. Family systems therapy should be employed with as much of the nuclear family as possible in session, as the family can serve as a microcosm to their home life (BCSF, 2021). Patterns of communication emerge in these sessions, along with the different alliances, rules, and expectations of the family. Intervention is very process oriented and emphasizes reflecting on the process, blocking negative patterns of interaction, or helping the family reframe their problem.

Responsiveness of Treatment

Publicly funded systems of care serving youth and families, such as community mental health settings, are likely to differ in complexity from controlled research settings under which most EBPs are developed and tested. Youth and families served in routine care are more likely to be racially and ethnically diverse (Southam-Gerow et al., 2012; Gellatly et al., 2019), and experience greater chronic and acute stressors (Marques et al., 2016; Southam-Gerow et al., 2008), socioeconomic marginalization (Alvidrez et al., 2019), complex and comorbid clinical presentation (Marques et al., 2016; Gellatly et al., 2019), and exposure to violence (McKay et al., 2005). Providers in community settings also often vary in professional background, therapeutic orientation, exposure to EBPs, and intensity of job demands (e.g., managing immense caseloads) that can relate to burnout (Kim et al., 2018; Lasalvia et al., 2009). Finally, publicly funded care settings frequently face organizational challenges, including limited resources to support the delivery of complex multicomponent EBPs, including resources to support ongoing training and consultation, fidelity monitoring, and performance feedback (Aarons et al., 2009; Beidas et al., 2016; Regan et al., 2017). Overall, multiple factors complicate the delivery of EBPs in routine care, given that clinical trials are often designed to filter out this variance (Chambers et al., 2013).

Lack of attention to addressing diverse needs during intervention delivery can pose barriers to treatment success, responsiveness, and client engagement. It can also widen mental health disparities for systemically marginalized groups, including Black and African American, Indigenous, Latinx, Asian American, Native Hawaiian and Pacific Islander, or multiracial youth and families, particularly those who are socioeconomically marginalized. It can also impact disabled and neurodivergent youth, as well as linguistic, sexual and gender minorities, (Barrera Jr. et al., 2017; Baumann & Cabassa, 2020). Thus, evidence-based practice necessitates clinician responsiveness to client heterogeneity and flexibility in adapting intervention delivery to youth and family needs across diverse care settings (Kendall, 2021).

Adaptation

Adaptation of treatment has been defined as a “process of thoughtful and deliberate alteration to the design or delivery of an intervention, with the goal of improving its fit or effectiveness in a given context” (Stirman et al., 2019, p. 1). Scholars from the cultural adaptation and implementation science literatures recommend a proactive, iterative, and dynamic approach to adaptation, wherein the reasons for (why, when) and process of (what) adaptation are systematically evaluated and documented (Aarons et al., 2012; Baumann et al., 2017), as well as informed by community stakeholder input (Barrera Jr. et al., 2017). Researchers have discouraged using assumptions or stereotypes about diverse groups to make unjustified changes to EBPs, in favor of a more selective, directed adaptation approach (Lau et al., 2006). Within this approach, adaptations are made only when supported by qualitative and quantitative data, such as when incorporating unique sociocultural factors or address limited engagement. Appropriate adaptations are designed with these data in mind (Castro et al., 2010; Lau et al., 2006). Although adaptations to EBPs have the potential to optimize care, they can also produce unintended consequences, such as omission of core EBP functions, if not guided by research, theory, or local expertise or context (Kirk et al., 2020; Stirman et al., 2019).

Of note, there has been some debate in the literature on the relationship between fidelity and adaptation to treatment. Fidelity to an EBP has been defined as the extent to which an intervention is delivered as intended in accordance with the EBP’s theoretical principles (Breitenstein et al., 2010; Hogue & Dauber, 2013). Treatment fidelity is thought to be associated with an EBP’s intended treatment outcomes (Collyer et al., 2020; Hogue et al., 2008; Thijssen et al., 2017), and thus substantial research has been invested towards understanding how to support providers and systems to deliver EBPs with fidelity (Eslinger et al., 2020; Garbascz et al., 2014; Lyon et al., 2018). Earlier debates in the literature centered on concerns of adaptations compromising EBP fidelity to the detriment of treatment outcomes (Elliot & Mihalic, 2004). However, there has been greater acknowledgement in recent literature that different types of EBP adaptations are likely to differ in their impact on outcomes and can complement intervention fidelity, and may enhance EBP implementation if consistent with an intervention’s key principles (Anyon et al., 2019; Pérez et al., 2016). Furthermore, the value an adaptation produces in EBP delivery and implementation can be overall positive, for example if it achieves goals of improved fit or reach, even if there are some costs (von Thiele Schwarz et al., 2019). However, given the need for more research on definitive links between different types of adaptations and outcomes, providers should aim to preserve the EBP’s core functions when making adaptations.

Direct Applications. Numerous frameworks within the cultural adaptation and implementation science literatures have been developed to guide the adaptation process. Common processes within these adaptation frameworks include identifying the core elements of the EBP known to impact treatment outcomes, establishing why adaptations are needed, delineating a process for making adaptations in ways that preserve the EBP’s core elements, piloting the adapted EBP, and finally monitoring and evaluating the adapted EBP (Texas Institute for Child & Family Wellbeing, 2016). Thus, the common elements approach to treatment may be a helpful foundation for guiding adaptation. This approach aims to identify the common elements of EBP for a given presenting problem by distilling the large number of available treatments in the literature down to the most common elements spanning these treatments (Chorpita et al., 2005). One way to adapt treatment effectively is to start with an EBP’s common elements and organize them into a tailored plan adapted to the specific needs of a child or family based on qualitative and quantitative data (Chorpita et al., 2014).

Relevant to psychosocial interventions, this section will discuss a few adaptation frameworks from the cultural adaptation and implementation science literatures. However, the authors acknowledge that there are many reasons to adapt, including to enhance treatment fit for different systemically marginalized groups, including for youth who are sexual and gender minorities, or who are socioeconomically marginalized, disabled, or neurodivergent, as well as for differences in provider, organization, and service setting characteristics.

Adaptations can be made prior to an intervention’s introduction into a service setting (“design-time”) or during its implementation or delivery in a setting (“run-time”) (Chorpita & Daleiden, 2014). Interventions can also be adapted through a top-down approach, in which an already existing intervention is adapted for other groups, or a bottom-up approach, in which an intervention is developed within a particular context to address the culture-specific aspects of that context, informed by the local community (Hall et al., 2016).

Cultural adaptations have been defined as those that “consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meanings, and values” (Bernal et al., 2009, p. 362). One influential cultural adaptation framework, the Ecological Validity Framework (Bernal et al., 1995),identifies eight dimensions that developers and providers should consider when assessing intervention fit: language, persons, metaphors, content, concepts, goals, methods, and context. Prior studies have used the Ecological Validity Framework as a guide for adapting youth and parenting interventions for culture, including for Puerto Rican, Haitian American, Hispanic, and Latinx youth and families, (Lee & Smith, 2013; Kuhn et al., 2020; Matos et al., 2006; Nicolas et al., 2009; O’Connor et al., 2020), as well as for autistic (Kuhn et al., 2020; Martinez-Torres et al., 2021), and deaf youth (Day et al., 2018). Some meta-analyses have suggested small to moderate improvements in outcomes for culturally adapted EBPs, including for Black and African American, Indigenous, Latinx, and Asian American youth and families (Hernandez Robles et al., 2016; Hodge et al., 2010; van Mourik et al., 2016). These studies have primarily focused on researcher-led, design-time adaptations.

Other well-recognized frameworks delineate the process of adaptation. The Cultural Adaptation Process Model (Domenech-Rodríguez & Wieling, 2005) and the Formative Method for Adapting Psychotherapy (Hwang, 2009) are two examples of bottom-up approaches that outline the process of adaptation in three and five phases, respectively. Both recommend consulting the relevant literature, notably collaborating with community stakeholders to gather knowledge and assess needs, integrating these knowledge bases to adapt the intervention, testing the adapted intervention, and introducing iterative adjustments if needed. Domenech Rodríguez & Bernal (2012) discuss other frameworks and guidelines that can be used to guide the adaptation process.

The Framework for Reporting Adaptations and Modifications–Expanded (FRAME; Stirman et al., 2019) is a prominent framework from the implementation science literature that offers a way to document the adaptation process and enumerates types of modifications that are made. The FRAME recommends documentation of when modifications occur (e.g., pre-implementation), how they arise (e.g., planned/proactive, planned/reactive), who initiates the modification (e.g., researcher, community member), the goals and reasons for modification, what was modified (e.g., content, context), at what level of delivery (e.g., individual, organizational), and the nature or type of modification. Examples of content modifications include tailoring the EBP, changing its packaging or materials, adding elements, removing/skipping elements, reordering modules, and integrating parts of another treatment into the EBP. Examples of contextual modifications include changes to the EBP format, setting, personnel (i.e., who delivers the intervention), or population that receives the intervention. The Model for Adaptation Design and Impact (MADI) expands on the FRAME by providing a decision aid for designing adaptations and assessing their intended and unintended impacts on implementation and intervention outcomes, as well as potential mediators and moderators of these impacts (Kirk et al., 2020).

There is a growing literature documenting local run-time adaptations that occur in routine care settings, including those that augment the EBP by adding to or taking away from the intervention in some way (Lau et al., 2017; Kim et al., 2020), there is some uncertainty regarding what adaptations in which contexts can maximize treatment outcomes. Thus, it is encouraged to characterize, document, and evaluate the impacts of these adaptations on client care and implementation outcomes in order to inform improvements to client care as well as to the reach and sustain EBPs in routine care (Chambers & Norton, 2016). It is important to understand what EBP adaptations optimize mental health outcomes for diverse youth and families, as these can inform improvements across care settings to reduce mental health disparities for marginalized groups.

Transdiagnostic Approaches

How would you treat someone with a problem list like the following: anxiety, depression, PTSD, substance use disorder? Protocol by protocol? Treatment as usual? As clinicians would agree, comorbidity is the rule, not the exception, and our clinical samples often show great heterogeneity (Norton, 2017). Transdiagnostic treatment is an approach independent of diagnosis that merges common elements of treatment protocols to enhance coverage of problem areas with generalizable therapeutic takeaways. In one study, 67% of participants with multiple diagnoses experienced remissions of their diagnoses to subclinical levels after participating in a transdiagnostic treatment (Norton, 2012). Similar data suggest that clients are amenable to transdiagnostic treatments delivered in community mental health settings, finding it acceptable (Norton, 2017). There are also benefits to delivering transdiagnostic treatments for both providers and supervisors. For providers, there is a reduced burden in being trained in one protocol compared to being trained in multiple protocols. Likewise, supervision may be easier to manage when using a unified approach.

Two protocols employing the transdiagnostic approach have been shown to be effective for youth: the Unified Protocol for the Treatment of Emotional Disorders in Youth (Ehrenreich et al., 2009) and the Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems MATCH-ADTC)(Chorpita & Weisz, 2009). The Unified Protocol for the Treatment of Emotional Disorders in Youth was adapted from the Unified Protocol for Adults (Barlow et al., 2004), and studies of this intervention have demonstrated effective outcomes for children (Carluci et al., 2021). MATCH-ADTC developed out of multiple meta-analyses of effective treatments for children, in which the active ingredients of those treatments were distilled (Weisz et al., 1995; Weisz et al., 2006), along with a clinical decision-making system matching different presenting problems to intervention elements.

Direct Applications. Individuals who have difficulty accessing resources and trainings for these approaches or other manualized protocols can take the common elements approach. Chorpita et al. (2005) extracted common elements of evidence-based treatments addressing youth mental health problems, distilled them down to the most common elements among these treatments, and matched these elements to specific youth presenting problems. Through the common elements approach, clinicians can deliver treatment flexibly while remaining in alignment with the tenets of evidence-based practice (i.e., what the literature says, what the clinician feels competent delivering, and what the client thinks of the treatments). PracticeWise, an organization dedicated to improving human health and welfare through the use of evidence and information technology to advance behavioral health care, has allowed us to reproduce a table from their work that outlines the common elements. Please consult the literature around common elements, the clinical dialogue below, or consult other PracticeWise materials to understand how to use them in a systematic way to maximize their effectiveness and clinician use of evidence.

Reproduced with permission from PracticeWise (2017).

Clinical Dialogues: Psychosocial Intervention with Bruce Chorpita, PhD

Sean E. Snyder, LCSW: Thanks again, Dr. Chorpita, for joining me for this clinical dialogue. I heard you speak at the ABCT Convention in 2019, and your talk about increasing the world’s therapeutic intelligence through strategic alignment of individuals, institutions and industries left a lasting impression on me. In the spirit of that talk, what would you say is the current state of intervention science? What do our readers need to know about what we need to know where we’re at with our interventions?

Bruce Chorpita, PhD: It’s a good question, because intervention sciences is not one thing. We’re doing pretty well at EBP testing, having documented what things work and what things help. Where we’re doing less well is the actionability of what we know. We have over 1200 randomized trials now for children’s mental health, and we have over 800 evidence-based treatments that meet what would be the equivalent of an APA, evidence-based standard. We have a wealth of knowledge about how to do things that will help children do better, and we are good at creating knowledge through testing protocols and discovering things in trials, and I would say that the state of the science now is not as far along with developing our strategies for how to make that science come to life.

Therapeutic intelligence refers to the idea that at any given moment, if you knew everything in those 1200 randomized trials, what would you do at any given moment with a child, whether you were a therapist, or whether you were a teacher, or a bus driver, or a soccer coach or anyone else who comes into contact with children? How would you behave in a way that fosters the psychological development, the emotional intelligence, the health and wellness of that child? Again, we know a lot about what to do if you read and knew all those trials. But even people like me who read for a living, I have to have a team of people help read those trials, and we still are catching up with the literature. So, our problem now is, how do we manage the fact that people have limited attention? They have limited time; they encounter an enormous amount of complexity if they’re helping children who have challenges. The question of how do we help them know what to do when that’s the case is highly underdeveloped at this point.

Snyder: The point of the book here, too, is to join that cause of making knowledge actionable through accessibility. The hope is to make things a little bit simpler for folks where they can rely on knowledge of common elements or thinking about what are those key ingredients that they need in order to get a child what they need.

Chorpita: We’re going to get into the elements piece, but fundamentally one of the issues that when we talk about the state of intervention science is that the unit of analysis of our intervention science is not the unit of analysis at which decisions are made in the service world. Fundamentally, in the literature, the policy now is you pick a program, and you administer the program with fidelity to a child; but decisions in the service world are made moment by moment, week by week. We don’t have units of knowledge from our literature that speak to that week by week, moment by moment decision making. Our literature is organized around the idea “a child has a problem, a child gets this program,” and “not tell me what happened this week, this is what’s in the foreground, what should we do in this moment?” The literature doesn’t answer those questions as well. And so, the whole idea of studying elements gets us closer to a unit of analysis that people in the service world tend to make their decisions, e.g., are we going to do relaxation skills this week? Are we going to work on our thinking patterns or social skills? Intervention science and the literature we have, it’s not as good at speaking to that decision, as opposed to which program should we pick for depression? It’s really a matter of how our literature is organized.

Where we would like to see things in the future is that, given the dynamic situation that we’re in, what should we do today? What we’ve been studying now in our lab is what happens in the middle of a session, if something goes wrong, and answer the question: what should we do? We call it the fire extinguisher principle; we don’t put a lot of fire extinguishers in our treatment programs that tell somebody, in writing, that “if this happens in runtime, this is what you do to get through this hour and consolidate some gains and be productive.” And what happens, as you might imagine, when we study folks who don’t have fire extinguishers? Things burn. We have lots and lots of hours of listening to therapists who get into these situations following a program, and either something goes wrong, or there’s a crisis that comes up, or some surprise happens. Everything goes off the rails, and it stays off the rails sometimes for multiple sessions even. We need to do better at preparing people in the service world, at answering that question, what do I do right now? Yes, this child has a diagnosis or problem, but also, what’s the present circumstances unfolding in front of me?

Snyder: There are two consequences I see from a system on fire. Clinicians get burned out because they feel “I am getting nowhere with my clients,” and their emotional burden increases. And then the flip side, clients aren’t engaged in the service because it’s not effective or the clinician is burned out, and the client might drop out. We are left with a burned-out therapist that may quit and a child that’s not getting treatment. It’s a snowball effect. We have to train more therapists because we have a shortage in an already small workforce and children do not get any better which impacts their quality of life, their schooling, their social life.

Chorpita: One of my wishes for intervention scientists is that people think more in terms of workforce capacity and not in terms of interventions. What we are trying to develop is a prepared workforce that, as you described, is a leaky bucket, right? Every year people are dropping out of the workforce, and you need to replace those folks. That expertise is always leaking out, because people are leaving, and we’re bringing in a new set of folks. Twenty years ago, the belief was “Train people in every EBT, or one for everything, then we as a field and workforce would be fine.” No one really thinks that you have to deal with turnover, you have to deal with the fact that the literature gets larger. Even if you train everybody in everything (which will never happen), the literature continues to grow, and knowledge always leaves the workforce, which means that we’re always losing ground on what’s known. Those are the kinds of things I don’t think we have enough people worrying about; how do we fill the capacity of that workforce, given that we’re always losing ground? It’s like walking up a down escalator. It feels like, how do you make progress when you’re always losing people from the workforce? And the literature keeps discovering new things that we didn’t know last year when we had cohorts of new trainees. The idea that we can train everybody in everything is a fantasy, and that failure has played out in multiple venues now.

Snyder: My mind instantly goes to task shifting or task sharing. Is that the ultimate path the field will have to take?

Chorpita: Absolutely, that’s what I mean when I mention the world’s therapeutic intelligence. Our mission is to democratize knowledge relevant to raising children in a healthy way, so the knowledge of evidence-based treatments doesn’t belong to credentialed people, some elite group of professors, or certified professionals. Ideally, anything that’s helpful to children that’s known through science is something that should be known to everyone immediately, and it should be made available when they need to know. So absolutely, our future with intervention delivery means taking on that idea of task sharing. It’s even a step further to say that everyone’s identity should be organized around this idea that we should behave in a way that’s therapeutically intelligent, that’s healthy to those around us. For instance, we should know when it’s best to be assertive with a child, and how to give instructions effectively. Or, if we expect compliance, we know how to notice and praise good behavior. This is a collective thing, where everybody from the grocery store clerk praising a child for good behavior to the baseball coach giving instructions clearly; it goes beyond “how do we recruit other roles into the healthcare workforce?” and it flips that to, “how do we make everything that is known actionable by anyone who is around children?” That’s the ultimate form of task shifting.

Snyder: It should be a natural instinct for us. For instance, a parent has a child who has a scrape on their knee. They go into the medical kit or cabinet; the parent knows what to do right away. Mental wellness needs that same thing, where people can have these things that are rooted in science ingrained in our identities of who we are and into our social fabric. All things being therapeutically intelligent.

Chorpita: That’s the world we want to live in, a world where, if your child can’t sleep, the worst-case scenario is you ask your wristwatch, “My child can’t sleep, what should I do?” And if there is an answer for that, you get the answer; if there are conditional answers, your wristwatch would ask you, “Before I can give you a good answer, I need to know: is your child a teenager? Well, here’s the best answer.” The fact is, the most common thing is not that we don’t know. It’s that we do know, but we don’t know how to get it to the person who needs to know. That’s the big problem we need to solve; that’s what the next 15-20 years is, developing that architecture of taking what’s already known and making it deliverable, and messaging it right to the person who needs to know it. If therapists are involved, great, I think there’ll always be a room. We’ll never have enough therapists.

Snyder: One of the core things I’ve taken away after reading your papers and looking at your body of work is this distillation and matching approach. That’s actually one of the inspirations for this book, considering the core things that clinicians need to know and what to implement in session, and the hope is to pull the curtain away from therapy and make that process less mysterious (thank you PracticeWise for letting us reproduce the common elements table in the chapter). So, let’s talk about getting necessary knowledge to the community clinician. How can a distillation and matching approach help them in their everyday practice?

Chorpita: I’ve two answers. The first one formally, is about that actual methodology and the tree view of the literature when you do this approach. We’re actually redoing it this year, by the way. In the last one, there were about 600 study groups and 300 randomized trials, and we now have about four times the size of the literature now, where there’s about 2800 psychosocial treatments and 1200 trials out there that we’ve looked at. This year, we’re rebuilding that tree, and we’re going to see what it looks like now that the literature is so large, now that we have a much bigger data set. The big takeaway from that methodology is that we need to think about the literature as a tree and not as a collection of separate buckets, with each bucket being for a particular population, like anxious kids in East LA or older kids in juvenile justice from South Carolina. That’s a fragmented model or view of the literature.

A tree has layers, and the first layer of the tree always seems to be the problem. If we put ethnicity, or age, or another factor in the model, what comes out in that first layer is based on the problem and the literature seems to show that different practices are suited to different problems. So, if you’re dealing with depression, there is a set of practices that seem to characterize what is helpful for depression. And those are different than the practices that are helpful for having disruptive behavior problems. And folks may ask, “Well, what about, representing diversity in the literature?” Well, that layer does come in, and when there’s evidence that effective treatments for one age group or gender or ethnic group are different than another, that’s a branch in the tree, but those branches are always higher up. If you can’t get into that complexity, it’s not a bad thing to start lower in the tree and consider what’s worked for anybody with depression. If you’re working lower in the tree, then you start looking at those interactions, you may find out older kids need a slightly different approach than younger kids, so then you adjust your approach. That methodology of thinking of the literature as this tree is helpful because our knowledge base and the tree keeps growing. It’s necessarily ending branches, but those branches are getting more robust.

Researchers are incentivized in academic science to produce or to accentuate the points of difference among all of these different interventions. As an intervention developer, I’m supposed to say, “how is my thing different from this other thing that already exists?” That’s literally the nature of getting a grant. It is to say, “What am I doing that’s different, and that’s better,” and so forth. At the end of the day, it produces this fragmentation. When you look at most CBT across hundreds and hundreds of CBT manuals, it’s pretty darn similar. As we were talking earlier about the actionability of the evidence base, actionability diminished when we disguise that similarity. When we say there are patterns here, in 1200, randomized trials and that there’s really only 30 or 40 things that represent the majority of what most providers will need to know, if we disguise that for the provider, we’re making it very hard to act on that evidence base.

The other big message about common elements is that in looking over the past 20 years since we’ve been starting to do this project, we found that level of analysis really has resonated with people almost to the point, beyond my comfort level sometimes, where people really have grabbed on to this idea of elements as a very helpful way of thinking about the science. People have really resonated with this idea of saying, “What are the secret ingredients to all these protocols?” And as a side result, it’s created a lot of amateur chefs in a way. People could put them together in a way that works for what’s in front of them, and as it turns out, the evidence seems to suggest that when given a set of elements and some guardrails and guidance, clinicians do remarkably well. If we control some decisions and offer some flexibility, people do remarkably well. The other big surprise from the elements is that there’s something intermediate between ultimate flexibility of doing anything you want and the highly structured approach of a protocol to manage uncertainty. There’s something in between where developers want to give you lots of structure, but we also want to allow you to make choices, moment to moment and week to week, within a set of limitations that we think are going to keep you going in a promising direction.

Snyder: That would probably take a lot of anxiety out of the process for therapists, that you can be within these parameters and really adapt to your setting. Social workers, we’re going to get thrown in places where there wasn’t a therapist before, like an afterschool program or park program. This elements approach can be a great roadmap from starting from the ground up in unique or non-traditional settings.

Chorpita: I do a lot of work with social work, and it’s very humbling. The world that most therapists live in is more complicated and less filtered than the world that intervention developers tend to work in. I don’t mean to broad brusque. I know there are some intervention developers who work with incredibly complex populations, but in general, the notion of inclusion and exclusion criteria right away tells me that you’re simplifying the world for a study in some way and saying we’re going to homogenize this group. We’re going to homogenize the set of options for a provider in a study by saying there’s one manual they can use, so you don’t have to deal with complexity. Use this one thing? That’s not the world providers face; they face like they have an infinite number of choices of what to do. In the research world, we’re pretending there’s only one manual in the world, and we’re now filtering down that there’s only one youth within a certain thing.

When you go into the real world of social work or community practice, you realize that complexity, that every child is dealing with something different. You the clinician have too many choices in some ways of what to do that day with your client. So, we try to hit this balance of saying, there is a clear message from the evidence base of things that work, and we’re trying to give you that toolbox. We’re trying to prepare you to know which tool is for what, we get very good results when we do that, and therapists seem to like that, too. Do whatever you want is less desirable than being prepared with the toolbox, which is more desirable than simply following a manual step by step by step without any choices at all.

Snyder: The golden mean! Building off of the common elements approach, you have the toolbox, you have the things in it, but what about the process of therapy? One of the articles that I loved reading, written by Dr. Alayna Park and company, was about therapists modifying content versus sequencing. What’s the takeaway for community practitioners from that article, the idea of modifying content versus sequencing?

Chorpita: First off, I’m so proud of Alayna because that was an honors thesis; she was an incredibly astute undergraduate here at UCLA, and now she’s a professor out of Palo Alto University. This was a topic that most undergraduates would not have touched, this idea that there’s more to practice than elements. To use your baking metaphor, you can’t throw together a bunch of ingredients and expect to get a good result. There is a recipe for how things are put together, and that recipe matters a lot. One of the things that made me uncomfortable in the past decade or so with the overwhelming enthusiasm for common elements was that it often turned into this idea that all we need is elements. I found myself a little concerned about that because that’s not the message that I got from the MATCH trial. For example, the first trial we did with John Weisz in Hawaii and in Boston, in which we actually compared two conditions that had the same elements and got different results. There were standard manuals using the same procedures as the MATCH program, which we literally designed that study. They had the same procedures and two conditions, and one did much better than the other. That tells you, the recipe really, really matters.

What Alayna was studying there was what do providers do when you give them a recipe, and what was interesting is that everybody seems to like to improvise. If you give people a very strict recipe, they still will improvise a little bit beyond the recipe. In other words, if you put up guardrails, people will go a little bit over the guardrail. If you move that guardrail out, or you move the fence out, people still like to lean over it anyway. And so, it was an interesting pattern that no matter what you do, where you set the flexibility in something, we found that providers would go right to the edge of that all the time. A takeaway for providers is to be aware that our natural bias is to keep going in the absence of guardrails. Our biases are to move out and be more flexible probably than we should be. We need some counter force to say, stay within a reasonable range here. No matter where we put the fence, everybody ended up leaning over the fence, and almost going over it.

Snyder: Here’s what you need to go crazy with it. But don’t go too crazy, right?

Chorpita: All things being equal, humans will see exceptions more than we see commonalities, right, that we ask that we’re good at detecting exceptions, and we sometimes are too quick to adapt before saying, “Let me try this before we adapt.” Some people might hear that and say, “Well, that doesn’t sound like the common elements guy.” But that’s really what I mean, like the distillation tree says, “Hey, start with what’s worked; the base of that tree has 600 studies on this topic that say, across all kids of every age, every cultural group, and so forth.” This is what we’re like, we want to start in these places, and if they work, we don’t necessarily need to be adapting all the time. It is our bias to want to customize everything.

Snyder: When you were initially giving your response, the first question about how do we make things actionable in real time made me think of behavioral economics, specifically the nudge framework. Are there things like that framework that can be helpful for clinicians with the problem of actionability, of how to make decisions in real time?

Chorpita: I think that will be the future. Eric Daleiden and I wrote in a paper in 2014, that the future of evidence-based practice is going to have to contend with ontologies and messaging. Ontologies is about how we apply a standardized set of terms and a known set of relationships among terms that allows us to synthesize the entire evidence base at once. The messaging part is how we then get the appropriate message delivered to the right person, at the right time, in the right unit of analysis, so that they can act. I like that you’re raising the idea of nudges. If you think of a treatment manual as a stimulus to produce change in a therapist, it’s really not how you would ever expect anyone to change their behavior, right? If I said, “I’m going to try to blast all of this training material in a three-day workshop, I’m going to have you read a book, you’re going to put the book on your bookshelf, and six months from now, when a case comes up, I’m going to expect you to recall smoothly, all those things.”

Now, that’s not exactly how we train; we do try to do practice cases and so forth. But the idea of having someone whisper to you moment by moment, “Try this, try that” or have your watch tell you, “Hey, you’re taking too long setting an agenda, or you didn’t set an agenda, it’s time to set an agenda. It’s time to move on to a roleplay,” contends with the fact that human attention will always wander and respond to different things. We do benefit from having those supports in everything we do. For instance, that’s why we have stop signs, right? We don’t have capacity for the mental effort of processing an intersection while driving and weighing the safety risk ratios of going through the intersection. It’s better to have those cues there to say, “this is when you stop.” Our ability to interact with other human beings and respond to those messages becomes smooth. We become coordinated; we become organized.

That’s the world we’re building for therapists, we want to democratize that and say anyone interacting with children should be getting those nudges, right? For the recess monitor on the school playground, what should they do if a child is crying? There’s probably an answer for that, and someone’s probably done a dissertation on that about; how do we message that to that person so they know how to provide the right type of support at that moment? That’s the world we want to build, to get science to people that need it in order to build healthy lives for children.

Snyder: It reminds me of PCIT, with the clinician in the caregiver’s ear, giving them those prompts on how to interact with the child in a therapeutic way. It’s working with the parent’s natural instincts that sometimes get crowded out with stress, et cetera.

Chorpita: That’s what’s brilliant about PCIT, that’s how you teach a parent, in vivo with the child in front of them. That’s how we should be teaching how to be a therapist. The only downside to that is that it represents a small evidence base of 10 of 1000 trials. It’s a chip off the tip of an iceberg of the evidence base that’s being represented through in-the-ear prompts. The other thing is that it’s not a cost-effective way to scale that evidence to a human. We need to somehow get machines to whisper, have machines to read, understand and organize our evidence base in a way where it behaves the way the semantic Web behaves. For example, with commerce, you can ask the internet a question about where to buy gas, and you get a great answer. We have not organized our evidence base of intervention that way yet.

Snyder: And that is the runtime aspect of care which is complex, and that is definitely the ideal, to harness AI and build that therapeutic infrastructure. So that’s the ideal, and let’s look at what’s happening in the community. The client cases we get are complex because they represent the rule, not the exception of comorbidity, and that makes me think about your team’s work with the Child STEP trials because they are in LA, it’s community clinics, where it’s not a lab setting. What did your team take away from those trials in the community clinics?

Chorpita: Aside from the fact that it’s always humbling to work in communities where there’s a high level of poverty and there’s all kinds of community stress going on and things like homelessness, we also had challenges among the providers themselves who were living in very stressful circumstances. It’s humbling to say, “let’s try to bring the evidence base to life in these particular contexts.” One of my takeaways for the MATCH trials is that it allowed us to answer a question that we were being asked based on a paradigm of evidence-based treatments. Prior to MATCH, we were doing common-elements type of work in Hawaii and enhancing the performance of that mental health system. As a result of that community level work in Hawaii, I was brought into the MacArthur Network, and over a period of about a year or so, we thought, “how would we configure the things we’re doing in Hawaii successfully, and put it in a trial?” The original design for the MacArthur Foundation trial was not to have a modular treatment condition. It was to test evidence-based treatments versus usual care in communities.

One of the things we do through Practice Wise is called Managing and Adapting Practice. It’s the big toolbox of everything in the literature, and for the trial, we picked 33 things that are equivalent to the same things in these three evidence-based manuals and put them into one toolbox that’s flexible. We predicted based on what I was doing in Hawaii that MATCH would be as successful as standard EBTs, but that therapists would like it better. The rationale we gave to the MacArthur Foundation was that if it’s as effective as EBTs, but therapists like it better, it will scale more quickly, and it will take off on its own. When the study is over, people will keep doing it and so forth. So, we set out to show it is as good as EBTs, but therapists like it more. Well, it turns out, we were right about one of those things: therapists do like it more, and we were wrong that it’s as good as established EBTs. We were surprised to find it actually was more effective than the standard EBTs. We believe it is because of the fact that dynamic delivery of treatment is more important than we realized.

So a key takeaway from intervention design from those MATCH trials (and even from some of the stuff we do with MAP) is that there are three things that intervention developers and therapists need to be aware of. One is that interventions need to be dynamic. We got burned with MATCH when we weren’t dynamic. In those trials, even though kids got better, and we did better than the gold standard EBTs, a lot of kids didn’t finish treatment. We had 40% of kids not really finishing a full course of treatment. Why? It’s because the treatment wasn’t dynamic in that way to deal with comorbidity. So if comorbidity comes up, we have tools in the toolbox. It was not dynamic enough regarding engagement. If engagement was poor in the middle of treatment, there was not a something in the flowchart that said, “Try this, and this will get you back, this will reengage the family, get you back on track.” We’re now building in that set of features into the next generation of MATCH. Being dynamic means having your fire extinguishers, assuming that things can go wrong, or things can change, and in real time, you have to be able to decide as things unfold in front of you.

The second thing is that treatment design needs to be developmental. Developmental means that not everybody needs to get the same protocol, because some people are already pretty skilled, and they need to get a few things, and they can stop treatment more quickly. Not everybody needs 16 sessions. With MATCH, some of our best cases were done in four or five sessions. And so being developmental means following people’s progress, meeting them where they are, and leaving them when they’re ready for you to leave them. Most of our interventions are not as developmental in nature, nor, by the way, are ways of training therapists how to do things. We always assume therapists know nothing when we meet them and that they have to learn everything again from us, even if they’ve learned it somewhere else. Be developmental.

The third one is diversity. Not everybody wants the same experience, even when they’re getting the same manual, so you may have to do the same procedure in a different way for a different child. A treatment developer is never going to anticipate the diversity, the dynamics, and the developmental characteristics of the treatment context. The person who writes the manual cannot say “I know all the different diverse individual differences you’re likely to encounter (e.g., poverty, homelessness, have a parent in the military).” There’s no way I could sit and write a manual and imagine all the things that are going to go wrong. I’m not going to imagine what are the starting points of different families, and I’m not going to imagine the different preferences and values that people are going to bring to the table. Putting those capabilities into the hands of the provider and preparing them not to respond on the fly and wildly improvising that may not actually be helpful. We don’t want therapists to improvise because we want to give them the tools to be able to be responsive on the fly.

So, the second takeaway from our community trials is that we don’t want people to improvise in ways that do more harm than good, but we also don’t want people to be reading a script. We want to give them something in between.

Snyder: That all reminds me of conversations I’ve had with colleagues at my clinic, where a common phrase is “When you’ve seen one case of autism, you’ve seen one case of autism.”

Chorpita: Exactly. That’s the reality, and we need the humility of saying that an intervention developer only knows what works for anxiety when a child’s cooperating with exposure. How often is that situation going to present itself, pure cooperation? Someone’s going to need to figure out what to do about that. That’s very humbling to know that a lot of what’s going on in session is in the therapist control because they’re looking through the window.

Snyder: As a clinician, if you feel good about your work, you’ll feel more in control, and if you feel more in control, you’re ultimately going to perform better. And when clinicians perform better, the child benefits, and if we go down this casual chain, systems benefit if we’re getting kids more quality treatment, and we can be more efficient with services which could hopefully reduce waitlists and treatment gaps.

With the last set of questions, I want to shift towards something that’s been in the public conversation in the past couple of years, that there’s a lack of representation of diversity in our scientific literature and that there is a lack of representation in who is doing the research (which is its own conversation). So, what would you say in regards to the idea that there is a lack of representation in the scientific literature? Does adaptation become the avenue forward?

Chorpita: This is a complex topic. There are so many assumptions, some of which aren’t always helpful. There are 200 evidence-based protocols for Hispanic youth, for instance; there are 235 for Black youth, and many clinical trials that have included Black youth and have produced an evidence base. I’ve seen claims that there’s no representation, but to me it’s more along the lines that there is no substantive representation. This points to the problems that come from those trials: what are the contexts that are going to create additional challenges for success? I don’t see it talked about nearly as much about in terms of racism and other contextual things like limited resources in someone’s community. We see it discussed in global mental health a little bit, where people talk about resource limitations and things. Those contexts can present extreme challenges for therapy to work well, which gets back to what I said before, what are those challenges going to unfold in front of people?

When we talk about adaptation, I’ll go all the way back to that distillation tree and say I still think we always have to start with the problem. In the absence of any other evidence, do we know what works for anyone for a particular problem? Because therapy is about managing the uncertainty of trying to help someone meet their goals. The best way to manage that uncertainty is to offer our best ideas (because total certainty is not realistic). Right, but we say where do I get my best ideas?

I should start with something that’s worked for somebody with a similar problem. You still do exposure with everybody who has anxiety, and we may need to tailor exposure considering that clients have different values, different beliefs, different cultural preferences. The challenge is to say how do I successfully manage to fit a procedure that I know to make this work in a particular context.

The word adaptation is tricky because I think of it more as how do I fit the best idea I can get from the evidence base into the context that I’m dealing with. Sure, we need to consider representation of underrepresented groups, but there’s also the neighborhood you’re in. What’s the level of violence, what’s the level of quality of education, what are the peers at that school modeling? All of those things are factors that are going to play in, and it’s not going to be as simple as saying a particular cultural group is going to get a culturally adapted treatment. There’s so much diversity within a cultural group. Aside from the fact that I think that making adapted protocols simply would create a factorial explosion because humans are so diverse, the actionability problem that we have now would be worse.

Some expertise is going to come from the evidence base like behavioral activation is a good idea for depression, exposure is a good idea for anxiety; and some expertise is going to come from local knowledge of the context. For instance, the evidence base that says humans tend to have elevated moods when we force them to do behaviorally activating procedures like going for a walk or calling a friend, and there’s the local context of knowledge of our clients, and the art of therapy is considering “How do I fit those two-evidence bases together?” I don’t think we’re ever going to store and document all of that stuff in a clinical trials evidence base because once we do, we will have a cohort effect. For instance, 10 years from now, we will say, “Well, the context changed, we didn’t have social media.” Ninety percent of these clinical trials in our evidence base were done before there was social media.

The evidence base is never going to give us all the answers, and so I might try to make this into a concise thing. I would say, we’re managing uncertainty, we have to be humble, and we have to say the evidence base has something to give us in terms of general messages, and the client’s contexts gives us other messages. We always need therapists who are local experts to say, “I am the translator of that science into this context.” Everything is local at the end of the day. If we try to imagine that the evidence base will always, always give us all the answers, we will never finish that project, and if we could finish that project, the evidence-base would be too large to be usable. We can’t read it; we can’t act on it. We have to get comfortable with this idea that local individuals have local expertise of the context and that they are allowed to drive the treatment as it unfolds. That’s what MATCH is all about, that the evidence basis is there to be helpful, and we can highlight a few principles from over a thousands of trial.

Snyder: The way forward then is setting up the architecture to make our knowledge actionable. You’re saying, how do we set up a therapist for success, how do we bridge those gaps of knowledge, how do we harness the context?

Chorpita: We call it a collaboration between the scientists and the therapists. A manual should be a collaboration. If I write out every last little thing you do in a manual, that’s not really collaborating because I’m not letting you, the therapists, do anything except what I tell you. Collaborating is saying what I know from science, and you’re going to make that unfold in a way, where what we both know is going to. Our job is to provide the messages when we feel, but, by all means, therapists are always going to be dealing with runtime issues of what’s in front of me. That’s what makes that job so cool and so interesting to me and keeps you going.

Snyder: I’m left with the theme of democratizing therapeutic intelligence, from scientists collaborating and practitioners, with practitioners joining with and collaborating with clients. So that’s the person-to-person democratization. And that springboards us to consider: how do we get people involved at large in active mental health promotion and wellness? Could you leave us with your last thoughts on that idea?

Chorpita: Anything that’s known to any human about what’s healthy should be knowable to every human, so we can be healthy. If humans have discovered something that’s helpful, everyone deserves to know it as soon as they need to. We as a field need to measure ourselves against that: how quickly can we get to that vision? We need to ask ourselves, how do we set up our institutions, the right way, to get things to people who need them.

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